HKJOT 2010;20(2):80–86

ORIGINAL ARTICLE

EVALUATION OF A HORTICULTURAL
ACTIVITY PROGRAMME FOR PERSONS
WITH PSYCHIATRIC ILLNESS
Michael C.Y. Kam1 and Andrew M.H. Siu2

Objective: To investigate the effect of applying horticulture activity on stress, work performance and
quality of life in persons with psychiatric illness.
Methods: This study was a single-blinded randomized controlled trial. Using convenience sampling,
24 participants with psychiatric illness were recruited to participate in a horticultural programme and
were randomly assigned to experimental and control groups. Two participants dropped out from experi-
mental groups after assignment. Ten participants in the experimental group attended 10 horticultural
sessions within 2 weeks, while 12 participants in the control group continued to receive conventional
sheltered workshop training. Participants were assessed before and after programme using Chinese
version of the Depression Anxiety Stress Scale (DASS21) and the Personal Wellbeing Index (PWI-C),
and the Work Behavior Assessment.
Results: There was a significant difference in change scores of the DASS21 (p = .01) between experi-
mental and control group. There were no significant differences in change scores of the PWI-C between
the two groups.
Conclusion: Horticultural therapy is effective in decreasing the levels of anxiety, depression and stress
among participants in this pilot study, but the impact of the programme on work behavior and quality
of life will need further exploration.

KEY WORDS: Horticulture • Horticultural activity • Psychiatric illness

Introduction improving interpersonal and vocational competence can serve

Persons with psychiatric illness frequently suffer from psy-
chosocial impairments like decrease in stress coping ability
and self-confidence, which resulted in deterioration in self care,
work and leisure (American Psychological Association, 1994).
The vulnerability-stress-coping competence model of mental
disorders proposed that psychobiological vulnerability may
result in psychotic symptoms when a person with vulnerability
to stress encounters stressful life events (Anthony & Liberman,
1986). Psychosocial interventions like stress coping skills,
as protective factors in the course of psychiatric disorders.
Horticulture is often known as gardening and horticultural
therapy in rehabilitation. In a comprehensive review of use of
horticulture in rehabilitation, Sempik, Aldridgem, and Becker
(2003) delineated the key differences between horticultural ther-
apy and therapeutic horticulture—Horticulture therapy is the
use of plants as a therapeutic medium by a trained professional
to achieve a clinically defined goal, while therapeutic horticul-
ture is more directed towards working with plants as a recre-
ational activity instead of aiming at achieving a therapeutic goal.

1
New Life Psychiatric Rehabilitation Association, and 2The Hong Kong Polytechnic University, Hong Kong SAR, China.
Reprint requests and correspondence to: Michael C.Y. Kam, New Life Farm Sheltered Workshop, 33 San Fuk Road, Tuen Mun,
Hong Kong SAR, China.
E-mail: michaelkam@nlpra.org.hk

80 Hong Kong Journal of Occupational Therapy

©2010 Elsevier. All rights reserved.

Horticulture has been widely adopted as a therapeutic
activity for persons with disabilities (Hefley, 1972; Kaplan &
Kaplan 1989; Wiesinger, Neuhauser, & Putz, 2006). Evidence
shows horticulture could promote physical and psychological
well-being (Sempik et al., 2003), and could be used in psy-
chotherapy and rehabilitation for persons with different needs
(Kaplan & Kaplan). In general, horticultural activity groups
has been found to promote social functioning, self-efficacy of
the persons with psychiatric illness who showed typical symp-
toms such as limitation in thought content, emotion and atten-
tion (Son, Um, Kim, Song, & Kwack, 2004). In a horticulture
therapy programme, participants learned to work with plants
in a therapeutic, vocational or recreational setting (Sempik et al.).
In general, there is evidence that programme conducted in out-
door environment often demonstrated more positive result
than programme conducted in indoor setting (Hewson, 2001;
Kaplan & Kaplan; Rodiek, 2002).
Many studies suggested that horticulture has different
benefits for persons with disabilities, but the benefits of horti-
culture on stress management and work performance were most
commonly mentioned. First, horticulture improves stress coping
skills of persons with and without illness. Unruh (2004) pro-
posed that gardening could be adopted as a kind of coping
strategy for persons with stressful life experiences. The horticul-
ture environment supports the healing process and the recovery
from stress for the persons with mental illness. Working or
walking in the healing gardens promotes rehabilitation in persons
with disabilities (Eling, 2006). Research studies found that
persons with psychiatric illness could benefit a lot from par-
ticipating in horticultural activities, such as reduction of stress
level and mental fatigue, stabilization of mood, alleviation of
psychiatric symptoms, enhancement in openness for reflection,
and acquiring a sense of tranquility and enjoyment (Armstrong,
2000; Eling; Kaplan, 1973; Smith, 1998; Wichorowski,
Whiteson, Haas, Mola, & Rey, 2005). Second, people perform-
ing gardening tasks often experience a sense of accomplishment
and productivity (Hefley, 1972; Wiesinger et al., 2006). Exposure
to plants could have a positive effect on attention, physical
health (Fjeld, Veiersted, & Sandvik, 2002) and work productivity
(Lohr, Person-Mims, & Goodwin, 1996). Persons with psy-
chiatric illness could achieve a sense of productivity and
employment through participating in structural horticulture
work, as persons could gain income and practice work skills
(Sempik et al., 2003). By providing goal orientated activities,
participants of horticulture programme can increase in self-
confidence, self-esteem and hence improve the quality of life
(Eling; Hefley; Wiesinger et al.).
This study investigated the effectiveness of horticultural
programme for persons with psychiatric illness in the New Life
Hong Kong Journal of Occupational Therapy
EVALUATION OF HORTICULTURAL ACTIVITY
Farm (NLF)—a sheltered workshop that uses horticulture
activities as key training activities. It is also a pioneer study in
applying horticulture for persons with mental illness in shel-
tered workshop in Hong Kong. The aim of this study was to
examine the effect of horticultural programme on stress cop-
ing skills, work behavior, and quality of life for persons with
psychiatric illness. Results of this study could examine
the evidence on applying horticulture in rehabilitation and
provide information to design more effective rehabilitation
service in future.
Methods
Participants
Twenty-four participants with severe mental illness were
recruited to participate in this study. There are 17 males and 7
females, and they have a mean age of 44.3 (SD = 11.6). More
than half (58.3%) of participants received secondary educa-
tion or higher. Participants were recruited if they are receiving
sheltered workshop or other vocational rehabilitation services,
had diagnosis of schizophrenia spectrum disorder (schiz-
ophrenia, schizoaffective disorder, schizophreniform disorder,
psychosis not otherwise specified), bipolar disorder, or major
depression and did not attend any similar horticultural pro-
gramme before. Participants were excluded if they were diag-
nosed with major physical or medical problems that could
interfere with participation in horticulture. There were two
drop-outs in the experimental group.
Procedures
This is a randomized controlled trial of horticulture therapy.
Participants were recruited by convenience sampling accord-
ing to the stated selected criteria. They were then assigned a
number and randomly allocated to the experimental (n = 12)
or control (n = 12) groups by an independent research assis-
tant (voluntary helper) who was blinded to the hypothesis and
the intervention programme (Figure 1). A registered occupa-
tional therapist (one of the investigators) was responsible for
implementing the horticultural programme in the experimen-
tal group. A blinded independent assessor (voluntary helper)
conducted all the outcome measurements before and after the
intervention programme.
Ethics approval was obtained from The New Life
Psychiatric Rehabilitation Association and the Hong Kong
Polytechnic University. Participants received briefing about
the purpose and procedures of the study to ensure that they
have a good understanding of the project. Written informed
consent was obtained from all participants prior to data
collection.
81
M.C.Y. Kam & A.M.H. Siu
Participants joined the programme
through convenience sampling (n = 24)
Assigned for eligibility for
participants who meet the
inclusion criteria (n = 24)
Participants meet inclusion criteria
and randomized (n = 24)
Experiment group Control group receive
receive horticultural conventional workshop
programme (n = 12) training (n = 12)
Drop out (n = 2)
Figure 1. Chart showing the recruitment and assignment of
research participants.
Intervention
The study was conducted in the New Life Farm, which was
established in 1968 as the first sheltered workshop in Hong
Kong adopting agriculture as rehabilitation media for persons
with psychiatric disability and/or mental handicap (New Life
Psychiatric Rehabilitation Association, 2009). Participants of the
workshop received conventional work-related skills training
on weekdays, including indoor industrial activities tasks (like
packaging) and outdoor horticulture tasks such as vegetable pro-
duction, processing, as well as vegetable delivery and conducting
farm tours.
The horticulture activity programme was a standardized
group that was conducted in 10 consecutive days within 2
weeks. The group objectives are: (a) to teach basic horticultural
knowledge and skills, and to develop interests in working with
plants, (b) to share relaxing experience and coping strategies
through working with plans, (c) to promote sharing and social
support among participations. Participants in the experimental
group attended a 1-hour horticultural activity session for 10
days. Once they finished the 1-hour horticulture session, they
joined the regular sheltered workshop training. Participants in the
control group remained in the conventional workshop training
throughout the study period.
Based on the work of previous studies (Olszowy, 1978;
Relf, 2005), each session of the standardized horticultural pro-
gramme have a specific theme and objectives, and all the main
82
HKJOT 2010;20(2)
activities were related to work with living plants (Table 1). In
each session, there is an introduction and warm-up, followed
by horticulture activities and group sharing. All the horticul-
ture activities took place in the five outdoor theme gardens of
the Farm, namely the Sensory Garden, Activity Garden, Farm
Garden, Display Garden and Practical Garden.
Instruments
Demographic data including age, gender, diagnosis and edu-
cation level were obtained at the baseline when the participants
joined the programme. Three standardized instruments were used
to measure outcomes of the programme and administered before
and after the intervention. Stress and coping was measured
using the Chinese version of Depression Anxiety Stress Scale
21 (DASS21), work performance was measured using Work
Behavior Assessment (WBA), and quality of life was measured
using Chinese version Personal Wellbeing Index (PWI-C). Semi-
structured interviews were conducted with participants of the
experimental group to obtain the qualitative evaluation data.
Depression Anxiety Stress Scale
It is a 21-item self-report instrument measuring current (“over
the past week”) symptoms of depression, anxiety and stress
(Lovibond & Lovibond, 1995). The DASS21 had adequate to
good internal consistency, and Cronbach’s α for the subscale
were .84 for Depression subscale, .77 for Anxiety subscale and
.86 for Stress subscale (Henry & Crawford, 2005). Taouk,
Lovibond, and Laube (2001) translated the DASS21 into
Chinese. They reported that the Chinese version of DASS21
was sensitive to cultural and linguistic issues, and could signifi-
cantly discriminate between the negative emotional syn-
dromes of depression, anxiety, and stress in Chinese populations.
It is particularly suitable for regular assessment and evaluation
of treatment outcome.
Work Behavioral Assessment
It is a 20-item behavioral scale for observation and rating of work
behavior on the subscales of Work Habit, General Work Behavior
and Work-related Social and Emotional Behavior (New Life
Psychiatric Rehabilitation Association, 2005). The WBA was
validated on 1211 clients attending vocational rehabilitation pro-
gramme in sheltered settings and community-based settings. The
WBA had high internal consistency (α = .94), good test-retest
reliability (ICC ranging from .80 to .91 for subscales), and inter-
rater reliability (r ranging from .77 to .91).
Personal Well-being Index–Chinese Version
The PWI-C is a subjective quality of life measure which
had been translated and validated for wide academic use in
Hong Kong Journal of Occupational Therapy

Table 1. Session titles and objectives of the horticulture activity programme
No. Session title
1 Orientation (Sensory, Activity, Farm,
Display, & Practical Gardens)
2 Organic Tips (Practical Garden)
3 Cultivation and Growth (Farm Garden)
4 Small Steps Toward Great Success (Farm Garden)
5 The Great Day (Farm Garden)
6 Herbs for Relaxation (Sensory Garden)
7 Be Tough as a Scarecrow (Activity Garden)
8 Taste the Herbs (Activity Garden)
9 Bringing It to Life (Activity Garden)
10 Grow With Support (Display Garden)
Hong Kong. It demonstrated good validity, reliability and sen-
sitivity in Chinese and other populations (Lau, Cummins, &
McPherson, 2005; Smyth, Nielsen, & Zhai, 2009).
Qualitative Evaluation
Semi-structured interviews were conducted to obtain feedback
about the horticulture programme. Semi-structured questions
were prepared to guide the interviews, and the scope ques-
tions included: (a) experience in the horticultural therapy pro-
gramme, (b) satisfaction with the programme, (c) perceived
benefits of the programme, (d) suggestions for improvement
of the programme. The recorded interviews were transcribed
and content analyzed to identify key themes in each of the
above topics.
Results
Using nonparametric tests, we found there were no significant
differences in gender distribution (p = .76), education level
(p = .10), diagnoses (p = .51) between experimental and con-
trol groups. Results of independent t test also showed that
there were no significant differences in the age (p = .56), and
baseline measures of the DASS (p = .29), the WBA (p = .30),
and the PWI-C (p = .53) (Table 2).
The changes in the outcome measures from the baseline to
post intervention for experimental and control groups are
listed in the Table 3. After intervention, there were significant
Hong Kong Journal of Occupational Therapy
EVALUATION OF HORTICULTURAL ACTIVITY
Session objectives
• Introduction to the programme.
• Garden tour.
• Give an introduction to organic farming.
• Review life story and successes in coping with life events.
• Teach and practice watering and fertilizing plants.
• Improve understanding about importance of protective factors
in coping with stress.
• Teach and practice weeds removal and loosening soil.
• Sharing of experience related to coping strategies.
• Teach harvesting skills, and how to examine and taste vegetables.
• Share about their past interests and successful events.
• Introduction to herbs, and make drawing of and identify different herbs.
• Share experiences related to their personal interests.
• Make a scarecrow.
• Share experience related to handicraft project and coping with stress.
• Make herb tea bags.
• Share strategies related to self-management of diet.
• Teach the procedures of potting plants
• Share their hopes, wishes, and future.
• Visit and introduction to greenhouse.
• Sharing on the activity group experience.
differences in the DASS-21 total (p = .01) and the Depression
(p = .04), Anxiety (p = .01) and Stress (p = .50) subscales.
However, there were no significant differences in the WBA
and its subscales (p ranges from .08 to .79) as well as the PWI
(p = .84) between groups (Table 3).
The qualitative data collected from the interviews could
be categorized into emotional, occupational, social and spiri-
tual aspects. The content analysis illustrated positive impact
and benefits, and some challenges expressed by participants
of the horticultural programme. Participants expressed that
the programme had emotional benefits such as the release of
work stress, enjoyment in natural environment. Social bene-
fits suggested include improvement of social skills, extension
of social network, a sense of being respected. The occupa-
tional benefits include the opportunities to learn new skills,
improve work performance, had better motivation to go to
work, and to use horticulture as leisure activity. They also
highlighted spiritual benefits such as an increase in self-
confidence, feel more connected with nature, and increase in
sensibility with plants. The most frequently mentioned adverse
effect was that they felt fatigue and tired during and after the
activities. The result of the interviews suggests horticulture
activities have a positive impact on the persons with psychi-
atric disabilities. It also reflected how horticultural activities
could serve as a means to achieve the goals of enhancing
occupational performance, and promote emotion health and
social performance.
83
M.C.Y. Kam & A.M.H. Siu HKJOT 2010;20(2)

Table 2. Comparison of demographic variables and baseline measures between experimental and control groups
Variables Experimental group (%) Control group (%) p

Demographic
Age 45.3 (10.38)a 43.3 (11.7)a .56b
Gender
Male 8 (67%) 9 (75%) .37c
Female 4 (33%) 3 (25%)
Diagnosis
Schizophrenia 10 (83%) 12 (100%) –
Other psychiatric illness 2 (17%) 0 (0%)
Education
No formal education 1 (8%) 0 (0%) .32c
Primary 6 (50%) 3 (25%)
Junior secondary 4 (34%) 6 (50%)
Senior secondary or above 1 (8%) 3 (25%)
Outcome measures
DASS total 21.8 (11.9)a 16.1 (14.2)a .32b
Depression subscale 14.6 (9.1)a 9.3 (8.9)a .74b
Anxiety subscale 15.0 (7.8)a 9.8 (8.7)a .84b
Stress subscale 12.6 (7.7)a 11.3 (10.8)a .17b
WBA total 59.9 (11.1)a 65.9 (14.6)a .30b
Work habit subscale 7.2 (1.5)a 7.7 (2.1)a .38b
Work performance subscale 24.2 (6.2)a 28.0 (8.5)a .44b
Work related social and emotion subscale 28.5 (5.3)a 30.3 (4.8)a .90b
PWI 49.5 (11.8)a 53.2 (14.9)a .53b
DASS = Depression Anxiety Stress Scale; WBA = Work Behavior Assessment; PWI = Personal Wellbeing Index. aValues presented as mean (SD);
b
p for t tests; cp for χ2 tests.

Table 3. Comparison of change scores between experimental and control groups

Outcome variable Experimental group (n = 10)a Control group (n = 12)a p

DASS
Depression subscale –9.20 (9.15) –1.17 (8.33) .04*
Anxiety subscale –9.00 (7.62) 0.67 (7.10) .01**
Stress subscale –6.00 (5.33) –0.50 (6.79) .05
Total –24.20 (17.78) –0.50 (6.78) .01*
WBA
Work habit subscale 0.10 (0.32) 0.16 (0.72) .79
Work performance subscale 2.70 (3.06) 0.92 (1.17) .08
Work related social & emotion subscale 0.90 (2.18) 0.42 (0.90) .49
Total 3.70 (4.42) 1.50 (2.28) .15
PWI
Total 0.60 (14.21) 1.50 (6.07) .84
DASS = Depression Anxiety Stress Scale; WBA = Work Behavior Assessment; PWI = Personal Wellbeing Index. t values are based on comparison
a

change scores, i.e. postintervention score minus baseline score. *p < .05. **p < .01.

Discussion
The results showed that the experimental group showed signifi-
cant decrease in anxiety, depression, and stress when compared
with the control group. This result was congruent with the previ-
ous studies which found that horticulture therapy had reduced
stress (Dijkstra, Pieterse & Pruyn, 2008; Kim & Mattson,
2002; Rodiek, 2002; Son et al., 2004) and depression (Kim &
Mattson; Lee, Ku & Ro, 2008; Son et al.; Wichrowski, 2005).
Consistent with the result of the interviews, participants also
reported more positive feelings as they participated in horti-
cultural activities. Participants expressed that they could relax

84 Hong Kong Journal of Occupational Therapy


from work and felt joyful in the horticultural environment during
the programme. Horticulture could serve as a kind of restorative
environment played a significant role in the recovery from
mental fatigue and induce therapeutic effects on mental health
(Kaplan & Kaplan, 1989).
Unlike the results of previous studies (Perrins-Margalis,
Rugletic, Schepis, Stepanski, & Walsh, 2000; Son et al.,
2004), this study did not support the benefits of horticultural
programme in improving work behavior. A marginally insignif-
icant result was obtained in work performance subscale of the
WBA (p = .076). However, in the interviews, many partici-
pants said the horticulture programme helps them to improve
work motivation and performance. It is likely that a horti-
cultural programme with high intensity of training is needed
to improve work performance. The horticulture programme in
many studies had many more training sessions and lasted for a
longer period of time, when compared to our programme. For
example, the programme conducted by Son et al. was imple-
mented twice a week for 5 months (around 40 sessions), and
the programme by Perrins-Margalis et al. (2000) was con-
ducted twice a week for 6 weeks (around 12 sessions). A pro-
gramme of longer duration (our programme was conducted
within 2 weeks) is needed to build up work behaviour.
The results of this study also did not support that horticul-
tural programme had a positive impact on quality of life.
Although participants expressed they had spiritual benefits in
the horticultural programme, the PWI instrument may not be
sensitive enough to reflect this over 2 weeks. Items in the PWI
aimed to check how satisfied participants were with their “life
as a whole” (Lau et al., 2004), and it may not be able to cap-
ture small changes in their life quality after 2 weeks of horti-
culture programme. There is a need to use a more refined
instrument or extend the duration of the programme.
There were several limitations to this study. Our total number
of participants was small in this pilot study. Future study should
be replicated with a larger sample size, which could increase the
power of the study. Also, while we tried to mainly recruit a homo-
geneous group of clients with diagnoses of schizophrenia and
psychosis, there are two participants in the study with other psy-
chiatric illness. There is a need to recruit a more homogeneous
client pool before random allocation is done. Lastly, no follow-up
assessment were conducted after the postintervention mea-
sure. There is a need to conduct follow-up assessment in future
studies, especially when the programme has a longer duration.
Conclusion
This pilot study aims to examine the evidence for horticultural
programme. The horticulture activity programme is effective
Hong Kong Journal of Occupational Therapy
EVALUATION OF HORTICULTURAL ACTIVITY
in reducing stress of persons with psychiatric illness, but did
not have a significant impact on work behavior and quality of
life. Further studies on horticulture activity programme need
to have a longer duration, so that we could examine its poten-
tial benefits on work behavior and quality of life.
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